Basic Critical Illness Insurance Definitions of Covered Conditions

Alzheimer's Disease

Alzheimer's Disease - means a definite Diagnosis of a progressive degenerative disease of the brain. The Insured Person must exhibit loss of intellectual capacity involving impairment of memory and judgment which results in a significant reduction in mental and social functioning and requires a minimum of 8 hours of daily supervision. The Diagnosis of Alzheimer's Disease must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for all other dementing organic brain disorders and psychiatric illnesses.

Aortic Surgery

Aortic Surgery - means the undergoing of surgery for disease of the aorta requiring excision and surgical replacement of the diseased aorta with a graft. Aorta refers to the thoracic and abdominal aorta but not its branches. The surgery must be determined to be medically necessary by a Specialist.  

Aplastic Anemia

Aplastic Anemia - means a definite Diagnosis of a chronic persistent bone marrow failure, confirmed by a biopsy, which results in anemia, neutropenia and thrombocytopenia requiring blood product transfusion, and treatment with at least one of the following: marrow stimulating agents; immunosuppressive agents; bone marrow transplantation. The Diagnosis of Aplastic Anemia must be made by a Specialist. 

Bacterial Meningitis

Bacterial Meningitis - means a definite Diagnosis of meningitis, confirmed by cerebrospinal fluid showing growth of pathogenic bacteria in culture, resulting in neurological deficit documented for at least 90 days from the date of Diagnosis. The Diagnosis of Bacterial Meningitis must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for viral meningitis.

Benign Brain Tumour

Benign Brain Tumour - means a definite Diagnosis of a non-malignant tumour within the cranial vault and limited to the brain, meninges, cranial nerves or pituitary gland. The Tumour must require surgical or radiation treatment or cause irreversible objective neurological deficit(s). The Diagnosis of Benign Brain Tumour must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for pituitary adenomas less than 10mm.

In addition, no benefit will be paid where Benign Brain Tumour is diagnosed, or signs, symptoms or investigations leading to the Diagnosis of a Benign Brain Tumour (regardless of when the Diagnosis is made) is initiated within 90 days following the issue date or the latest reinstatement date of Member's Critical Illness coverage.

Blindness

Blindness - means a definite Diagnosis of the total and irreversible loss of vision in both eyes evidenced by:

• the corrected visual acuity being 20/200 or less in both eyes; or
• the field of vision being less than 20 degrees in both eyes.

The Diagnosis of Blindness must be made by a Specialist. 

Cancer (Life-Threatening)

Cancer (Life-Threatening) - means a definite Diagnosis of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The Diagnosis of Cancer must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for the following non-life threatening cancers:

• Carcinoma in situ; or
• Stage 1A malignant melanoma (melanoma less than or equal to 1.0mm in thickness, not ulcerated and without Clark level IV or V invasion); or
• Any non-melanoma skin cancer that has not metastasized; or
• Stage A (T1a or T1b) prostate cancer.

Coma

Coma - means a definite Diagnosis of a state of unconsciousness with no reaction to external stimuli or response to internal needs for a continuous period of at least 96 hours and for which period the Glasgow coma score must be 4 or less. The Diagnosis of Coma must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for:

• A medically induced coma; or,
• A coma which results directly from alcohol or drug use; or,
• Diagnosis of brain death. 

Coronary Artery Bypass Surgery

Coronary Artery Bypass Surgery - means the undergoing of heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s) excluding any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction. The surgery must be determined to be medically necessary by a Specialist.

Deafness

Deafness - means a Diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The Diagnosis of Deafness must be made by a Specialist.

Heart Attack

Heart Attack - means a definite Diagnosis of the death of heart muscle due to obstruction of blood flow, that results in a rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:

• Heart attack symptoms;
• New electrocardiographic (ECG) changes consistent with a heart attack;
• Development of new Q waves during or immediately following an intra-arterial cardiac procedure including but not limited to, coronary angiography and coronary angioplasty;
• The Diagnosis of Heart Attack must be made by a Specialist

Exclusions: No benefit will be payable under this condition for:

• Elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography or coronary angioplasty in the absence of new Q waves; or
• ECG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition described above

Heart Valve Replacement

Heart Valve Replacement - means the undergoing of surgery to replace any heart valve with either a natural or mechanical valve. The surgery must be determined to be medically necessary by a Specialist.

Exclusion: No benefit will be payable under this condition for heart valve repair.

Kidney Failure

Kidney Failure - means a definite Diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The Diagnosis of Kidney Failure must be made by a Specialist. 

Loss of Independent Existence

Loss of Independent Existence - means a definite diagnosis of:

• A total inability to perform, by oneself, at least 2 of the following 6 Activities of Daily Living; or
• Cognitive Impairment as defined below, for a continuous period of at least 90 days with no reasonable chance of recovery. The Diagnosis of Loss of Independent Existence must be made by a Specialist.

Activities of Daily Living are:

• Bathing - the ability to wash oneself in a bathtub, shower or by spongebath, with or without the aid of equipment;
• Dressing - the ability to put on and remove necessary clothing including braces, artificial limbs or other surgical appliances;
• Toileting - the ability to get on and off the toilet and maintain person hygiene;
• Bladder and Bowel Continence - the ability to manage bladder and bowel function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained;
• Transferring - the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment;
• Feeding - the ability to consume food or drink that already have been prepared and made available, with or without the use of adaptive utensils.

Cognitive Impairment - means mental deterioration and loss of intellectual ability, evidenced by deterioration in memory, orientation and reasoning, which are measurable and result from demonstrable organic cause as Diagnosed by a Specialist. The degree of Cognitive Impairment must be sufficiently severe as to require a minimum of 8 hours of daily supervision. Determination of a Cognitive Impairment will be made on the basis of clinical data and valid standardized measures of such impairments.

Exclusion: No benefit will be payable under this condition for any mental or nervous disorder without a demonstrable organic cause.

Loss of Limbs

Loss of Limbs - means a definite Diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as a result of an accident or medically required amputation. The Diagnosis of Loss of Limbs must be made by a Specialist.  

Loss of Speech

Loss of Speech - means a definite Diagnosis of the total and irreversible loss of the ability to speak as a result of physical injury or disease, for a period of at least 180 days. The Diagnosis of Loss of Speech must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for all psychiatric related causes.

Major Organ Failure on Waiting List

Major Organ Failure on Waiting List - means a definitive Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under Major Organ Failure on Waiting List, the Member must be enrolled as the recipient in a recognized transplant centre in Canada or United States of America that performs the required transplant surgery. The date that insured Member is enrolled in the transplant centre will be deemed the date of Diagnosis for this Covered Condition. The Diagnosis of the major organ failure must be made by a specialist.  

Major Organ Transplant

Major Organ Transplant - means a definite Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow and transplantation must be medically necessary. To qualify under Major Organ Transplant, the insured Member must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The Diagnosis of the major organ failure must be made by a Specialist.  

Motor Neuron Disease

Motor Neuron Disease Motor Neuron Disease - means a definite Diagnosis of one of the following: amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), primary lateral sclerosis, progressive spinal muscular atrophy, progressive bulbar palsy or pseudo bulbar palsy, and limited to these conditions. The Diagnosis of Motor Neuron Disease must be made by a Specialist.

Multiple Sclerosis

Multiple Sclerosis - means a definite Diagnosis of at least one of the following:

• Two or more separate clinical attacks, confirmed by a magnetic resonance imaging (MRI) of the nervous system, showing multiple lesions of demyelination; or
• Well-defined neurological abnormalities lasting more than 6 months, confirmed by MRI imaging of the nervous system, showing multiple lesions of demyelination; or
• A single attack, confirmed by repeated MRI imaging of the nervous system, which shows multiple lesions of demyelination which have developed at intervals at least one month apart.

The Diagnosis of Multiple Sclerosis must be made by a Specialist. 

Occupational HIV Infection

Occupational HIV Infection - means a definite Diagnosis of infection with Human Immunodeficiency Virus (HIV) resulting from accidental injury during the course of the Member's normal occupation, which exposed the Member to contaminated body fluids. The accidental injury leading to the infection must have occurred after the later of the issue date or the latest reinstatement date of the Member's coverage.

Payment under this condition requires satisfaction of all of the following:

• The accidental injury must be reported to the insurer within 14 days of the accidental injury;
• A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative;
• A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;
• All HIV tests must be performed by a duly licensed laboratory in Canada or the United States of America;
• The accidental injury must be reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

The Diagnosis of Occupational HIV infection must be made by a Specialist.

Exclusion: No benefit will be payable under this condition if:

• the Member has elected not to take any available licensed vaccine offering protection against HIV, or;
• a licensed cure for HIV infection has become available prior to the accidental injury or;
• HIV infection has occurred as a result of non-accidental injury including but not limited to, sexual transmission and intravenous (IV) drug use.

Paralysis

Paralysis - means a definite Diagnosis of the total loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a period of at least 90 days following the precipitating event. The Diagnosis of Paralysis must be made by a Specialist.  

Parkinson's Disease

Parkinson's Disease - means a definite Diagnosis of primary idiopathic Parkinson's Disease which is characterized by a minimum of two or more of the following clinical manifestations: muscle rigidity, tremor, or bradykinesis (abnormal slowness of movement, sluggishness of physical and mental responses). The insured Member must require substantial physical assistance from another adult to perform at least 2 of the following 6 Activities of Daily Living. The Diagnosis of Parkinson's Disease must be made by a Specialist.

Activities of Daily Living are:

• Bathing - the ability to wash oneself in a bathtub, shower or by sponge bath, with or without the aid of equipment;
• Dressing - the ability to put on and remove necessary clothing including braces, artificial limbs and surgical appliances;
• Toileting - the ability to get on and off the toilet and maintain personal hygiene;
• Bladder and Bowel Continence - the ability to manage bowel and bladder function with or without protective undergarments or surgical appliances so that a reasonable level of hygiene is maintained;
• Transferring - the ability to move in and out of a bed, chair or wheelchair, with or without the use of equipment;
• Feeding - the ability to consume food or drink that already have been prepared and made available, with or without the use of adaptive utensils.

Exclusion: No benefit will be payable under this condition for all other types of Parkinsonism.

Severe Burns

Severe Burns - means a definite Diagnosis of third-degree burns over at least 20% of the body surface. The Diagnosis of Severe Burns must be made by a Specialist.

Stroke (Cerebrovascular Accident)

Stroke - means a definite Diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or haemorrhage, or embolism from an extra-cranial source with:

• Acute onset of new neurological symptoms; and
• New objective neurological deficits on clinical examination, persisting for more than 30 days following the date of Diagnosis. These new symptoms and deficits must be corroborated by diagnostic imaging testing.

The Diagnosis of Stroke must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for.

• Transient Ischaemic Attacks; or
• Intracerebral vascular events due to trauma; or
• Lacunar infarcts which do not meet the definition of stroke as described above.

Definitions of AdvanceCare Benefit Conditions

Coronary Angioplasty 

Coronary Angioplasty - means the undergoing of an interventional procedure to unblock or widen a coronary artery that supplies blood to the heart to allow an uninterrupted flow of blood. The procedure must be determined to be medically necessary by a Specialist.  

Early Stage Cancer

Early Stage Cancer - refers to one of the following conditions:

• Malignant Melanoma - means an invasive malignant melanoma into the dermis equal to or lower than a depth of 1.0mm;
• Stage A Prostate Cancer (T1a or T1b);
• Ductal Carcinoma in situ in the breast

The diagnosis of Early Stage Cancer must be made by a Specialist.